to the availability of teaching aids, more so because of the breach while proceeding with tissue removal. With
endoscopic camera. Last but not the least, the skill of experience, a surgeon's complication rate would certainly
experienced endoscopic surgeon who operates looking at be reduced. The best way to keep the complication rate
the monitor that automatically serves the purpose of down to minimum would be to do a thorough preoperative
demonstration is also an essential requisite.
evaluation, use very careful surgical techniques and give
painstaking attention to proper postoperative care.
One has to start with diagnostic endoscopy to study Inadequate practical knowledge of the anatomy of
anatomy and normal anatomical variations and then go on paranasal sinuses as also of the evolution of the
pathophysiology of various diseases result in inadequate
clearing of the diseases and greater number of
complications. A wise surgeon is the one who recognises
the complication and treats it there and then. Lastly, the
wisdom lies in knowing when not to use endoscopes e.g.
intracranial complication, osteomyelitis, infiltrative lesions,
invasive fungal infections etc.
to surgery beginning with minor procedures viz. excision
of concha bullosa, anterior ethmoidectomy, anterior
ethmoidectomy with middle meatus antrostomy, posterior
ethmoidectomy and sphenoethmoidectomy. And only then
should one venture into advanced endoscopic procedure
like dacryocystorhinostomy, optic nerve decompression,
excision of pituitary adenoma (where simultaneous use
of drill is necessary) or closure of CSF rhinorrhoea, etc.
To start with, one must operate on virgin cases and keep
revisions for more experienced colleagues. One also has
to get familiar with reading the CT scans. The eyes must
be trained to point out the dangerous anatomical variations,
viz., naked optic nerve, dehiscent lamina papyracea etc.
These must be borne in fffind during surgical steps as
they may not alwayTtre pointed out by the radiologist
since they may not be manifestly involved. Defects and
destructions due to pathology or previous surgery may
be missed while reporting.
CONCLUSION
Endoscopic sinus surgery has a lot to offer as far as
management of paranasal sinus diseases is concerned.
Before attempting endoscopic sinus surgery:
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. One must have thorough knowledge of anatomy as
well as pathophysiology.
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3
4
5
. Cadaver dissection training.
. Observed or assisted endoscopic sinus surgery.
. Should start with diagnostic endoscopy.
. Begin with minor surgical procedure only then move
onto advanced surgery.
A word about cranial bone studies. Cadaveric dissection
is significantly helped by an endoscopist having an intimate
knowledge of a normal skull - a skull wherein the sinus
anatomy of the various septa has been carefully retained.
Holding the skull in various postitions - full skull or in
section - and then viewing the nasal cavities, provides a
clarity of thought that facilitates not only cadaveric
dissection but live endoscopy as well.
It would be unfair to our patients to embark on endoscopic
surgery without undergoing a self training course as
mentioned above.
REFERENCES
1.
Kirtane. M.V. from "Functional endoscopic Sinus Surgery", by
M.V. Kirtane, 1993;19-21. Monograph published by M. V.
Kirtane on behalf of Seth G. S. Medical College and K. E. M.
Hospital, Diamond Jubilee Society Trust. Bombay - 12.
The complication rates of endoscopic sinus surgery are
found to be higher than those with traditional external
ethmoidal surgery, although the anatomical relations
remain the same. The incidence of complications varies
from surgeon to surgeon and helps in differentiating the
experienced one from the novice. Most complications
occur because of losing anatomical orientation, failure to
appreciate relationships of vital structures in relation to
fovea, posterior ethmoid and sphenoid, working blindly
in a blood filled field and not recognising an anatomical
2. Mosher. H. P. : Surgical anatomy of ethmoidal labyrinth. Ann
Otol Rhinol Laryngology 1929; 38:869-901.
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3. Stammberger, H. : Endoscopic endonasal surgery - concepts in
treatment of recurring rhinosinusitis. Part I. Anatomic and
Pathophy siologic Considerations. Gtolaryngol Head Neck Surg.
94; 143:1986.
Address for Correspondence :
H. K. Marfatia
2/85, Yeshwant Nagar, Goregaon (w),
Bombay.
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